Corporate Medical Policy - Blue Cross and Blue Shield of North ...

Corporate Medical Policy 

Extracorporeal Shock Wave Treatment for Musculoskeletal 

Conditions and Wound Healing 

File Name: extracorporeal_shock_wave_treatment_for_musculoskeletal_conditions 

Origination: 

Last CAP Review: 

Next CAP Review: 

Last Review: 

1/2001 

7/2012 

7/2013 

7/2012 

Description of Procedure or Service 

Extracorporeal shockwave treatment (ESWT), also known as orthotripsy, has been available since 

the early 1980s for the treatment of renal stones and has been widely investigated for the treatment 

of biliary stones. Shock waves create a transient pressure disturbance, which disrupts solid 

structures, breaking them into smaller fragments, thus allowing spontaneous passage and/or removal 

of stones. The mechanism by which ESWT might have an effect on musculoskeletal conditions is 

not well defined. Chronic musculoskeletal conditions, such as tendinitis, can be associated with a 

substantial degree of scarring and calcium deposition. Calcium deposits may restrict motion and 

encroach on other structures such as nerves and blood vessels, causing pain and decreased function. 

One hypothesis is that disruption of these calcific deposits by shock waves may loosen adjacent 

structures and promote resorption of calcium, thereby decreasing pain and improving function. 

Other functions are also thought to be involved. Physical stimuli are known to activate endogenous 

pain control systems and activation by shock waves may “reset” the endogenous pain receptors. 

Damage to endothelial tissue from ESWT may result in increased vessel wall permeability, causing 

increased diffusion of cytokines, which may in turn promote healing. Microtrauma induced by 

ESWT may promote angiogenesis and thus aid in healing. Finally, shock waves have been shown to 

stimulate osteogenesis and promote callous formation in animals, which is the rationale for trials of 

ESWT in delayed union or non-union of bone fractures. 

Currently, 5 ESWT devices are approved for marketing by the U.S. Food and Drug Administration 

(FDA). The OssaTron® device (HealthTronics, Marietta, GA), an electrohydraulic delivery system 

was approved by the FDA on July 20, 2000, for patients with chronic proximal plantar fasciitis— 

i.e., pain persisting more than 6 months and not responding to conservative management. It is also 

FDA approved for treatment of lateral epicondylitis (tennis elbow). The Epos Ultra (Dornier, 

Germering, Germany), an electromagnetic delivery system, was approved by the FDA on January 

15, 2002, for plantar fasciitis. The SONOCUR® Basic (Seimans, Erlangen, Germany) also uses an 

electromagnetic delivery system and was approved by the FDA for use in chronic lateral 

epicondylitis (symptoms unresponsive to conservative therapy for more than 6 months) on July 19, 

2002. In 2005, the Orthospec Orthopedic ESWT (Medispec Ltd, Germantown, MD), an 

electrohydraulic spark-gap device, and the Orbasone Pain Relief System (Orthometrix, White 

Plains, NY), a high-energy sonic wave system, received approval for treatment of chronic proximal 

plantar fasciitis in patients 18 years of age or older. 

Both high-dose and low-dose protocols have been investigated. A high-dose protocol consists of a 

single treatment of high energy shock waves (1300mJ/mm2). This painful procedure requires 

anesthesia. A low-dose protocol consists of multiple treatments, spaced 1 week to 1 month apart, in 

which a lower dose of shock waves is applied. This protocol does not require anesthesia. The FDAlabeled 

indication for the OssaTron® and Epos Ultra device specifically describes a high-dose 

An Independent Licensee of the Blue Cross and Blue Shield Association 

Page 1 of 9



protocol, while the labeled indication for the SONOCUR® device describes a low-dose protocol. 

Another type of ESWT, radial ESWT (rESWT) received pre-market approval (PMA) in May 2007. 

The FDA-approved device is the Doloclast (spelled Dolorclast in the PMA summary) from EMS 

Electro Medical Systems, Nyon, Switzerland. Radial ESWT is generated ballistically by 

accelerating a bullet to hit an applicator, which transforms the kinetic energy into radially 

expanding shock waves. Other types of ESWT produce focused shock waves that show deeper 

tissue penetration with significantly higher energies concentrated to a small focus. Radial ESWT is 

described as an alternative to focused ESWT and is said to address larger treatment areas, thus 

providing potential advantages in superficial applications like tendinopathies. 

Sanuwave Health, Inc. (Alpharetta, GA), has developed a device using shock wave therapy to treat 

diabetic foot ulcers. The dermaPACE® system was recently evaluated in a company-sponsored 

double-blinded, randomized Phase III, Investigational Device Exemption (IDE) clinical trial. 

DermaPACE® was compared with Sham-control (non-active treatment), combined with current 

standard of care for the treatment of diabetic foot ulcers. (NCT00536744) At this time, 

dermaPACE® has not received FDA approval. 

Plantar Fasciitis 

Plantar fasciitis is a very common ailment characterized by deep pain in the plantar aspect of the 

heel, particularly on arising from bed. While the pain may subside with activity, in some patients 

the pain may persist, interrupting activities of daily living. On physical examination, firm pressure 

will elicit a tender spot over the medial tubercle of the calcaneus. The exact etiology of plantar 

fasciitis is unclear, although repetitive injury is suspected. Heel spurs are a common associated 

finding, although it has never been proven that heel spurs cause the pain. It should be noted that 

asymptomatic heel spurs can be found in up to 10% of the population. 

Conservative therapy of plantar fasciitis is successful in the vast majority of cases. Rest or 

minimization of running or jumping is the cornerstone of therapy. Heel cups are sometimes helpful 

in alleviating symptoms, presumably by padding the heel and absorbing the impact of walking. 

Nonsteroidal anti-inflammatory drugs are also helpful in acute cases. If these measures are 

ineffective, a local injection of steroids may be effective. Improvement is frustratingly slow and 

gradual, taking up to a year in some cases. 

Tendinitis of the Elbow (Lateral Epicondylitis) 

Lateral epicondylitis is the most common form of tendinitis of the elbow and results in lateral elbow 

pain and functional limitations. The disorder is caused by overuse or injury of the tendons that 

attach the arm muscles to the elbow, such as commonly occurs from playing tennis (“tennis 

elbow”). However, only a minority of cases is caused by playing tennis, the majority occur from 

other activities that involve repetitive extension of the wrist. Overuse of the extensor muscles leads 

to microtears at their insertion point, which incites an inflammatory response. Repetitive cycles of 

injury and inflammation lead to tendinosis, degeneration of the tendon structures, and disorganized 

healing. 

The diagnosis of lateral epicondylitis is made by characteristic pain and tenderness at the lateral 

aspect of the elbow, in conjunction with typical activities or injury that accompany this condition. 

Radiologic imaging is not necessary for diagnosis, but may be useful in ruling out other causes of 

lateral elbow pain, such as fracture, dislocation, degenerative joint disease, and other bony or soft 

tissue pathologies. Imaging is usually normal in lateral epicondylitis, although occasionally calcium 

deposition can be seen. 





Policy 

Conservative treatment consists of rest, activity modification, anti-inflammatory medications, 

and/or physical therapy. Corticosteroid injections and orthotic devices can also be tried as adjuncts 

to conservative measures. A number of surgical treatments are available for patients who do not 

respond to conservative treatment; approximately 5%–10% of patients with tendinitis of the elbow 

require surgery. Surgery may be performed as open or laparoscopic procedures. The general 

approach is to debride any degenerative or nonviable tissue and to repair tears or other structural 

abnormalities. 

***Note: This Medical Policy is complex and technical. For questions concerning the technical 

language and/or specific clinical indications for its use, please consult your physician. 

Extracorporeal shockwave treatment for musculoskeletal conditions and wound healing is 

considered investigational. BCBSNC does not cover investigational services. 

Benefits Application 

This medical policy relates only to the services or supplies described herein. Please refer to the Member's 

Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; 

therefore member benefit language should be reviewed before applying the terms of this medical policy. 

When Extracorporeal Shock Wave Treatments are covered 

Not Applicable 

When Extracorporeal Shock Wave Treatments are not covered 

Extracorporeal shock wave therapy (ESWT), using either a high- or low-dose protocol or radial 

ESWT, is considered investigational, as a treatment of the following clinical conditions, including 

but not limited to: 

• plantar fasciitis; 

• tendinopathies: including tendinitis of the shoulder, and tendinitis of the elbow 

(epicondylitis, tennis elbow); 

• stress fractures; 

• delayed union and non-union fractures; 

• avascular necrosis of the femoral head; 

• wound healing; 

• spasticity 

Policy Guidelines 

Extracorporeal shock wave therapy (ESWT) has been investigated for use in a variety of musculoskeletal 

conditions. Differences in treatment parameters among studies, including energy dosage, method of 





generating and directing shock waves, and use or absence of anesthesia, limit generalizations from results 

of multiple studies. The precise mechanism of action of ESWT and the impact of anesthesia on outcomes 

continue to be matters of discussion. 

Data as to the effectiveness (impact on net health outcome) of ESWT in the treatment of musculoskeletal 

conditions remains inconclusive, including in the FDA-approved indications for plantar fasciitis and 

lateral epicondylitis. Therefore, the benefits of this technology in the treatment of musculoskeletal 

conditions, including plantar fasciitis, lateral epicondylitis, patellar tendonitis, tendonitis of the shoulder, 

fracture nonunion, or osteonecrosis of the femoral head, remain unknown. 

There is inconclusive medical and scientific evidence in peer-reviewed medical literature that 

extracorporeal shock wave therapy for diabetic foot ulcers has a beneficial effect on health outcomes. 

Efficacy and safety of radial ESWT in the treatment of spasticity in patients with cerebral palsy has 

been examined in a small RCT from Europe in 2011. Additional study with a larger number of 

subjects is needed to permit conclusions regarding the efficacy of this technology on spasticity. 

Delayed Union: 

Delayed union is defined as a decelerating healing process as determined by serial x-rays, together 

with a lack of clinical and radiologic evidence of union, bony continuity or bone reaction at the 

fracture site. 

Nonunions: 

The FDA labeling simply suggests that nonunion is considered established when the fracture site 

shows no visibly progressive signs of healing, without giving any guidance regarding the time 

frame of observation. However, it is suggested that a reasonable time period for lack of visible signs 

of healing is 3 months. The following patient selection criteria are suggested, consistent with those 

proposed for electrical stimulation as a treatment of nonunions: 

• At least 3 months have passed since the date of the fracture, AND 

• Serial radiographs have confirmed that no progressive signs of healing have occurred, AND 

• The fracture gap is 1cm or less, AND 

• The patient can be adequately immobilized and is of an age when he/she is likely to comply 

with non-weight bearing. 

Billing/Coding/Physician Documentation Information 

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it 

will be reimbursed. For further information on reimbursement guidelines, please see Administrative 

Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in 

the Category Search on the Medical Policy search page. 

Applicable codes: 0019T, 0101T, 0102T, 0299T, 0300T, 28890 

BCBSNC may request medical records for determination of medical necessity. When medical records are 

requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all 

specific information needed to make a medical necessity determination is included. 

Scientific Background and Reference Sources 





Consultant Review - 01/2001 

Specialty Matched Consultant Advisory Panel - 8/2001 

BCBSA TEC Bulletin - 12/28/2001 

Ogden JA, Alvarez R, Levitt R et al. Shock wave therapy for chronic proximal plantar fasciitis. Clin 

Orthop Rel Res 2001;387:47-59. 

Chen HS, Liang-Mei C, Huang TW. Treatment of painful heel syndrome with shock waves. Clin 

Orthop Rel Res 2001;387:41-46. 

Rompe JD, Hopf C, Nafe B, Burger R. Low energy extracorporeal shock wave therapy for painful 

heel: a prospective controlled single-blind study. Arch Orthop Trauma Surg 1996;115:75-79. 

Rompe JD, Kullmer K, Riehle HM; Herbsthofer B, et al. Effectiveness of low-energy extracorporeal 

shock waves for chronic plantar fasciitis. Foot and Ankle Surgery 1996;2:215-221. 

BCBSA Medical Policy Reference Manual, 2/15/2002; 2.01.40 

BCBSA TEC Evaluation, Volume 16, No. 20, April 2002 

Specialty Matched Consultant Advisory Panel - 5/2003 

BCBSA TEC Assessment, Volume 18, No. 5, August 2003 

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.40, 11/9/04 

BCBSA TEC Assessment, Volume 19, No. 16, February 2005 

BCBSA TEC Assessment, Volume 19, No. 18, March 2005 

Institute for Clinical Systems Improvement (ICSI). Technology Assessment Reports #86. 

Extracorporeal shock wave therapy for plantar fasciitis (November 2004). Retrieved 3/1/07 from 

http://www.icsi.org/technology_assessment_reports_- 

_active/ta_extracorporeal_shock_wave_therapy_for_plantar_fasciitis.html 

California Technology Assessment Forum (CTAF)--Extracorporeal Shock Wave Therapy (ESWT) 

for Musculoskeletal Disorders (June 9, 2004). Retrieved 3/2/07 from 

http://www.ctaf.org/content/general/detail/544 

California Technology Assessment Forum (CTAF)--Extracorporeal Shock Wave Therapy (ESWT) 

for the Treatment of Lateral Epicondylitis (October 20, 2004). Retrieved 3/2/07 from 

http://www.ctaf.org/content/general/detail/545 


National Institute for Clinical Excellence (NICE). Extracorporeal shockwave therapy for refractory 

tendinopathies (plantar fasciitis and tennis elbow). Interventional Procedure Guidance 139. London, 

UK: NICE; November 2005. Retrieved 3/1/07 from 

http://www.nice.org.uk/pdf/ip/IPG139guidance.pdf 

Canadian Agency for Drugs and Technologies in Health (CADTH). Extracorporeal shockwave 

treatment for chronic plantar fasciitis (heel pain). (January 2007). Retreived 2/15/07 from 





http://www.cadth.ca/media/pdf/E0009_chronic-plantar-fasciitis-part1_cetap_e.pdf 


treatment for chronic lateral epicondylitis (tennis elbow). (January 2007). Retreived 2/15/07 from 

http://www.cadth.ca/media/pdf/E0012_chronic-lateral-epicondylitis-part2_cetap_e.pdf 


treatment for chronic rotator cuff tendonitis (shoulder pain). (January 2007). Retreived 2/15/07 

from http://www.cadth.ca/media/pdf/E0013_chronic-shoulder-pain-part3_cetap_e.pdf 


National Institute for Clinical Excellence (NICE). Guidance on extracorporeal shockwave therapy 

for refractory plantar fasciitis. Interventional Procedure Guidance 311. London, UK: NICE; August 

2009. Retrieved on May 18, 2010 from 

http://www.nice.org.uk/nicemedia/live/11187/45188/45188.pdf 


for refractory Achilles tendinopathy. Interventional Procedure Guidance 312. London, UK: NICE; 

August 2009. Retrieved on May 18, 2010 from 

http://www.nice.org.uk/nicemedia/pdf/IPG312Guidance.pdf 


for refractory tennis elbow. Interventional Procedure Guidance 313. London, UK: NICE; August 

2009. Retrieved on May 18, 2010 from http://www.nice.org.uk/nicemedia/pdf/IPG313Guidance.pdf 

California Technology Assessment Forum (CTAF). Extracorporeal shockwave therapy (ESWT) for 

plantar fasciitis not responding to conservative therapy. October 28, 2009. Retrieved on May 18, 

2010 from http://www.ctaf.org/sites/default/files/assessments/1074_file_ESWT_2009_W_final.pdf 

Greve JM, Grecco MV, Santos-Silva PR. Comparison of radial shockwaves and conventional 

physiotherapy for treating plantar fasciitis. Clinics. 2009 February; 64(2): 97–103. Retrieved on 

June 28, 2010 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2666476/?tool=pubmed 


Specialty Matched Consultant Advisory Panel review 7/2010 

Ibrahim MI, Donatelli RA, Schmitz C et al. Chronic plantar fasciitis treated with two sessions of 

radial extracorporeal shock wave therapy. Foot Ankle Int 2010; 31(5):391-7. 

Greve JM, Grecco MV, Santos-Silva PR. Comparison of radial shockwaves and conventional 

physiotherapy for treating plantar fasciitis. Clinics (Sao Paulo) 2009; 64(2):97-103. 

Thomas JL, Christensen JC, Kravitz SR et al. The diagnosis and treatment of heel pain: a clinical 

practice guideline-revision 2010. J Foot Ankle Surg 2010; 49(3 Suppl):S1-19. 

Barnes M. Letter to the editor. "Low-energy extracorporeal shock wave therapy as a treatment for 

medial tibial stress syndrome". Am J Sports Med 2010; 38(11):NP1-2. 

Chen JM, Hsu SL, Wong T et al. Functional outcomes of bilateral hip necrosis: total hip 

arthroplasty versus extracorporeal shockwave. Arch Orthop Trauma Surg 2009; 129(6):837-41. 

Cacchio A, Giordano L, Colafarina O et al. Extracorporeal shock-wave therapy compared with 





surgery for hypertrophic long-bone nonunions. J Bone Joint Surg Am 2009; 91(11):2589-97. 

Zelle BA, Gollwitzer H, Zlowodzki M et al. Extracorporeal shock wave therapy: current evidence. J 

Orthop Trauma 2010; 24(Suppl 1):S66-70. 

Wang CJ, Liu HC, Fu TH. The effects of extracorporeal shockwave on acute high-energy long bone 

fractures of the lower extremity. Arch Orthop Trauma Surg 2007; 127(2):137-42. 



Food and Drug Administration (FDA) Clinical Trial #NCT00536744. Effectiveness of 

dermaPACE Device and Standard Treatment Compared to Standard Treatment Alone for Diabetic 

Foot Ulcers. Retrieved on December 5, 2011 from http://clinicaltrials.gov/ct2/show/NCT00536744 

Medical Director review 12/2011 

Vidal X, Morral A, Costa L et al. Radial extracorporeal shock wave therapy (rESWT) in the 

treatment of spasticity in cerebral palsy: a randomized, placebo-controlled clinical trial. 

NeuroRehabilitation 2011; 29(4):413-9. 


National Institute for Health and Clinical Excellence (NICE). Extracorporeal shockwave therapy for 

refractory greater trochanteric pain syndrome. 2011. Retrieved on April 2, 2012 from: 

http://www.nice.org.uk/nicemedia/live/12975/52604/52604.pdf 



Jeon JH, Jung YJ, Lee JY et al. The effect of extracorporeal shock wave therapy on myofascial pain 

syndrome. Ann Rehabil Med 2012; 36(5):665-74. Retrieved from 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3503942/ 


Policy Implementation/Update Information 

01/01 New policy issued. 

07/01 Policy re-titled. Name changed from Extracorporeal Shock Wave Lithotripsy for 

Orthopedic Problems to Lithotripsy, Extracorporeal, for Orthopedic Problems. 

8/01 Specialty Matched Consultant Advisory Panel. No changes. 

1/02 Changed policy to cover Extracorporeal shock wave lithotripsy for plantar fasciitis 

according to criteria stated in policy. Remains investigational for all other musculoskeletal 

problems. 

5/02 Revised to include "chronic proximal" plantar fasciitis for clarification. Typos corrected. 

Format changes. 





9/02 Medical director review. Revised section under when it is covered to clarify criteria. 

Added numbers 4. and 5. a. - c. Typos corrected. 

11/02 Policy revised under when it is covered and when it is not covered to include criteria for 

chronic lateral epicondylitis. Criteria numbers 4. and 5. a. - c. were moved under the Policy 

Guidelines section. Format changes. System coding changes. 

2/03 Policy revised under the Description section to include low and high energy shock waves. 

Policy Guidelines revised to include low and high energy shock wave therapy. Codes G0279 and 

G0280 added to Billing/Coding section. 

2/03 Terms added to the Medical Term Definitions. 

5/03 Specialty Matched Consultant Advisory Panel review. No criteria changes. 

4/04 Benefits Application and Billing/Coding sections updated for consistency. 

6/2/2005 Specialty Matched Consultant Advisory Panel review on 5/23/2005. No changes 

made to policy statement. Code descriptions removed. SUR6323 added as key word. References 

added. 

7/07/2005 Codes 0101T and 0102T added to Billing/Coding section. 

8/18/2005 Coverage criteria section of the policy revised as following: 1. (no change) 2. 

Changed " There has been a lack of response over at least 6 weeks..." to "There has been a 

documented lack of response over at least 6 weeks..."; "a. rest" changed to "a. rest (defined as use 

of a cast boot or cessation of painful activities for plantar fasciitis); "b. physical therapy" changed 

to "b. a formal physical therapy program, which can include either compliance with a home exercise 

program taught in the physician’s office (in which case the specifics of the program as well as 

specific references to compliance must be documented in the record; merely referring to 

"stretching" is not sufficient) OR supervised physical therapy in a physical therapy facility 

documented by appropriate records"; "c. anti-inflammatory medication" changed to "c. antiinflammatory 

medication (name of medication, dose and frequency must be specified)"; d. (no 

change) e. (no change) 3. (no change). Additional notation made in this section, "Please note: 

information supplied in cover letters does not replace the need to provide copies of office records to 

document compliance with the criteria above." Notification given 8/18/2005. Policy effective date 

10/20/2005. 

1/05/06 CPT Codes G0279, G0280, 0020Tdeleted and CPT Code 28890 added to Billing/Coding 

section. 

7/2/07 Item 1 in the When Lithotripsy is Covered section revised to read: The history in the record 

must be of sufficient detail to establish chronicity of symptoms for at least 6 months. (This consists 

of persistent symptoms over a 6 month period of time with no more than 4 weeks of symptom-free 

time after prior interventions.) References updated. Specialty Matched Consultant Advisory Panel 

review 5/18/07. (adn) 

7/6/09 Specialty Matched Consultant Advisory Panel review 5/21/09. No change to policy 

statement.(adn) 

For Policy Renamed: Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions 

9/28/09 Policy name changed from Lithotripsy, Extracorporeal, for Orthopedic Problems to 

Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions. Description section 





extensively revised. Policy statement changed to read: BCBSNC will not provide coverage for 

extracorporeal shockwave treatment for musculoskeletal conditions. It is considered investigational 

and BCBSNC does not cover investigational services. Information in the When Covered section was 

deleted and replaced with the statement: "not applicable." Information in the When Not Covered 

section was deleted and replaced with the following: "Extracorporeal shock wave therapy (ESWT), 

using either a high- or lo-dose protocol or radial ESWT, is considered investigational, as a 

treatment of musculoskeletal conditions, including but limited to: plantar fasciitis; tendinopathies, 

including tendinitis of the shoulder and tendinitis of the elbow (epicondylitis, tennis elbow); stress 

fractures; delayed union and non-union fractures; avascular necrosis of the femoral head." 

Notification given 9/28/09. Effective date 1/01/10. (adn) 

08/17/10 Specialty Matched Consultant Advisory Panel review 7/2010. Medical Policy number 

removed. References updated. (mco) 

4/26/11 Description section updated. References updated. Policy Guidelines updated. No change to 

policy statement. (mco) 

8/16/11 Specialty Matched Consultant Advisory Panel review 7/2011. No changes to policy 

statements. (mco) 

For Policy Re-titled: Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions 

and Wound Healing 

12/30/11 Policy re-titled to “Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions 

and Wound Healing.” “Description” section updated to include information on dermaPACE®, new 

ESWT for treatment of diabetic foot ulcers. “When not Covered” section updated to include wound 

healing as an investigational clinical condition. 0299T and 0300T added to “Billing/Coding” 

section. New codes to be effective 1/1/2012. “Policy Guidelines” section updated. References 

update. Medical Director review 12/2011. (mco) 

5/1/12 “When not Covered” section updated to include treatment of spasticity. Policy Guidelines 

updated. References updated. Medical Director review 4/2012. (mco) 

8/7/12 Specialty Matched Consultant Advisory Panel review 7/2012. No changes to Policy 

Statement. (mco) 

4/1/13 References updated. Policy Guidelines updated. No changes to Policy Statement. (mco) 

Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined 

before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and subscriber 

certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only and 

is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of 

disease. Medical practices and knowledge are constantly changing and BCBSNC reserves the right to review and revise its 

medical policies periodically.

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